The success stories of medicine deserve more attention

The success stories of medicine deserve more attentionA guest column by the American College of Physicians, exclusive to KevinMD.com.

It has all of the features of a talk radio discussion that you might encounter in any US city: Commentators (many of them anonymous) at one extreme or the other of a topic, name-calling, blaming, and empty rhetoric overshadowing the real issues. I am referring to the recent hullabaloo over several recently published essays on physician career dissatisfaction.

If you missed them, you may want to read the following before going any farther: How Being a Doctor Became the Most Miserable Profession, by Dr. Daniela Drake, which started the recent uproar, A Doctor’s Declaration of Independence, a similarly themed op-ed in the Wall Street Journal, and two responses to Dr. Drake, Tedious Paperwork, Government Regs: Why I Still Love Being a Physician, and Sorry, being a doctor is still a great gig. There are many more, but these will give you the general idea.

Like many other subjects, this one generated many passionate comments, but little conversation. Some physicians think that Dr. Drake was on target, while others feel she went over the top with her commentary. Some are piling on with their perspectives of how horrible being a doctor is and accuse those who challenge this view of being dismissive or insensitive. At the other end of the spectrum are physicians who see the criticisms as whining and opine that regardless of the challenges, there are rewards to being a doctor that far outweigh the negatives. Then there are those who are hitching all that’s wrong with medicine to their pet peeve du jour, blaming Obamacare, maintenance of certification, electronic health records, the government, and organized medicine for all of our troubles.

Lost in the back and forth that followed Dr. Drake’s piece are the real issues behind the dissatisfaction that many of us have felt at one time or another (or longer) about being a doctor. By “us,” I include myself, since there was a time that I was unhappy enough to consider changing what I was doing. Very few of the causes of discontent are new. In fact, perhaps the first use of the term “hassle factor” to describe the administrative, regulatory, and paperwork burdens that physicians face was in a paper by the American Society of Internal Medicine (ASIM), America’s Health Care System Strangling in Red Tape, published in 1990. In 1990, Barack Obama was a law student at Harvard, board certification was for life, there was no RUC, and physicians documented on paper (without having to follow documentation guidelines to support E/M codes), yet if you read the physician testimonials on page 6 of the ASIM paper, they could have been written in 2014.

Of course, since 1990, additional reasons for physician grief have emerged, but so have solutions to some of those problems. I know physicians who have reclaimed their professional satisfaction by becoming employed, while others have left employment to start their own practices and are happy they did so. Some converted their practices to direct pay (“concierge,” “retainer-based”) while others joined colleagues to form larger groups to take advantage of economies of scale, increase leverage with insurers and hospitals, and decrease isolation. While technology has dealt an additional blow to many physicians already under siege, it has made it possible for others to streamline their operations, reduce overhead, and manage a reasonable workload (so-called “micro practices”).

My own professional redemption resulted from two events. The first was a business decision that reduced my overhead significantly and created a more stimulating practice environment, when my two-physician office consolidated with a three-physician office that was part of our large group. The second was practice transformation, when we became a patient-centered medical home and embraced the team-based care model. The consolidation improved my bottom line without my having to see more patients or find other ways to increase revenue. Team-based care reduced many of my hassles, by transferring many of the administrative tasks that I shouldn’t have been doing in the first place to other members of the team.

These are not “one size fits all” solutions to physician career dissatisfaction, and they do not change the “macro” contributors to our unhappiness such as the dysfunctional payment system, an even more dysfunctional tort system, user-unfriendly electronic health records, and the angst over board certification.

These big issues need to be addressed, and while we can argue over whether we’ve made any progress since 1990, there is still much more to do. Nonetheless, there are many success stories out there. They do not sugarcoat the realities of practicing medicine, but offer hope to those who would like to get back to what they intended to do when they chose this profession, and deserve more attention than they’re getting in the current discussion.

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    For some reason I am compelled to look at the ASIM report in a different way. Everything those physicians said almost a quarter century ago, can be said today multiplied by orders of magnitude. We did nothing to address their concerns, and health care costs have exploded by orders of magnitude as well. Isn’t there a lesson to be learned here?
    I am certain individual doctors can carve out little niches for themselves, where they can feel less harassed for a little while longer, but shouldn’t the sheer existence of the ASIM report tell us that a system wide solution is highly overdue?

    • Yul Ejnes, MD, MACP

      Of course, a system-wide solution is overdue. But in the absence of consensus on what that solution should be (as much as there is wide agreement that there needs to be a solution, when you get down to the specifics, there goes the wide agreement), and a critical mass of stakeholders to make it happen, we can try to improve what “system” we have.

      I must respectfully disagree with your comment that nothing has been done to address the concerns raised in 1990 and in the more recent commentaries. If you look at the list of recommendations in the 1990 paper, many of them were eventually implemented. But looking at the big picture, those recommendations could be viewed as nibbling around the edges, trying to make an inherently dysfunctional system more functional. Perhaps not enough, or too little too late, but better than sitting by the sidelines and doing nothing at all.

      As to the examples that I described, I would invite colleagues who have found a way to improve their situations to tell us whether they see what they did as a short-term reprieve from the insanity or as a long-term solution to their problems.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Yes, some of the nitty gritty carrier rules that make the bulk of that article have been addressed with various degrees of success, and electronic claims are now a fact of life, but I think you would be hard pressed to find a significant number of physicians who think that the “hassle factor” has indeed been reduced, because for every little thing given two big things were taken away (so to speak).

        I do agree that sitting on the sidelines is not a particularly effective strategy. However, I see the solutions described here as largely tactical, and I think there is a lack of a strategic direction that can unify physicians for a common goal.
        For example, your small practice is now part of larger one, but is that new practice large enough? How long can it hold out before it gets swallowed by one of the, say, two health systems left standing in the neighborhood? It may take a while, and perhaps another merger to achieve a bigger size, and you may be retired by then, but is this a real long term solution? What is the tiny practice in a more rural area, where there are no big groups, to do?

        I don’t know, Dr. Ejnes, maybe this is directed more at the ACP (and all other medical societies) than at you as a practicing physician who found a good personal solution, which is a great thing in and of itself….

        • Yul Ejnes, MD, MACP

          The other reality, unfortunately, is that as some hassles were eliminated, others appeared to take their place, or some of the fixes had unintended consequences. For example, practice guidelines were seen as a way out of capricious coverage decisions by insurers, but for many they became the hassle of P4P, PQRS, etc. Back in 1990, we thought EMRs would save us time and improve efficiency. For most of us, it’s been a mixed bag at best. And so on.

          I do think that there is a practice size and market share that provides protection from being swallowed up and that we’ve achieved it. But you are correct that this is not a solution for all. There are other models, such as IPAs, that could work for the smaller practices. It’s my hope that readers who practice in various settings and have found ways to mitigate some of the barriers to professional satisfaction will chime in with comments.

          The organizations have heard the message – AMA has this as one of its three strategic goals and it’s been on ACP’s radar for as long as I can remember. But in addition to having to move immovable objects, they have to deal with disagreement among constituents of what constitutes success – one person’s solution is another person’s failure. Just look at how parts of the ACA, such as the primary care bonus and Medicaid/Medicare payment parity, are applauded by some and derided by others. But as I noted elsewhere, one thing that the societies can help with is providing practice support that won’t make the external pressures go away but may make them less damaging to the practice. And we will continue to try to make the external pressures go away.

  • Yul Ejnes, MD, MACP

    I do appreciate your thoughtful and collegial comments, but I do need to call out your incorrect assumptions about my experiences and perspectives as a practicing internist. You don’t know me personally (at least, I don’t think so, since you’re using a screen name), so I am not sure how you seem to know what I do or don’t do or what I do or don’t understand.

    Believe me, I missed enough of my boys’ teacher conferences, Little League games, and Boy Scout events, skipped paychecks because there wasn’t enough money left in the checking account after paying all the other office bills, and sat in my family room after the late news (or in my hotel room late at night after ACP meetings) working on my EHR enough times to know what it’s like. And I continue to practice in a private office (for almost 25 years) where a huge chunk of my revenue comes from fee-for-service and my pay is whatever is left after my share of the rent, utilities, staff, supplies, taxes, etc. are taken out (even if I am not in the office because of my organized medicine work).

    I welcome you to weigh in on whether you agree or disagree with my column(s) and the opinions that I express, but your presumption that because a physician makes it to the leadership of a medical organization he or she is somehow disconnected from the realities of practice is way off base. (And if you would like to know how one can get involved but still make a living in private practice, I would be happy to share that with you by e-mail or on the phone.)

    As to the the issues that you say I brushed aside, I have written about some of them in other KevinMD columns – my intention in this one was to focus on one specific area (in 800 words or so). And I’ll probably cover some of them in future columns, so stay tuned.

    • guest

      With all due respect, physician leaders who are trying to reassure the rest of us that the medical profession is not in dire straits (and destined to worsen), would probably be more effective if they could offer concrete and specific examples rather than vague generalities.

      I for one would be fascinated to hear in what specific ways your patient-centered medical home has relieved you of burdensome administrative scut. Many of us have had very opposite experiences, and so having someone whose involvement in active clinical practice is unclear (thanks for clarifying, by the way), assure us that everything works out great for them, without offering details, is not particularly reassuring or uplifting.

      • Yul Ejnes, MD, MACP

        The point that I made in my first paragraph was that as a society, for many of the issues that we debate, it seems that we end up in binary mode – it’s either this way or not – when in fact, there are many shades in between. So if one recites a list of wrongs, some will brand that person a whiner, and if someone challenges whether things are really as bad as all that, they’re called naive or insensitive. This issue is more complicated than that, as most are, and I believe that we are smart enough to avoid the “you’re either with us or against us” mentality that pervades so much public discourse today.

        So was my goal to reassure the rest of us (or all of us, since I’m part of the “us”) that we’re not in dire straits? No, but I do confess to challenging the “sky is falling” theme of some of the recent commentaries and providing some examples of how things don’t have to be so bad, even if the challenges remain.

        I’ve written about my practice experience in other columns for KevinMD.com, http://www.kevinmd.com/blog/2014/01/changed-private-practice-glass-empty-full.html and http://www.kevinmd.com/blog/2013/01/acp-learned-medical-home.html, and a column in ACP Internist http://www.acpinternist.org/archives/2012/03/presidents.htm . I plan to cover the topic in more detail in a later column.

        But to answer your questions in the meantime, a few examples of reducing hassle include having medical assistants fill out prior auth forms using information already in the record, so I just have to review the forms, supply any missing information, and sign. Soon, our practice’s clinical pharmacists will take this on. Other forms, such as the now-ubiquitous employer forms to “prove” that a patient had a health screening, are also handled by the MAs, and reviewed by us before signature. We have a protocol for automatic renewal of chronic medications by the MAs. Our nurse care manager works with the MAs to track down patients who are overdue for diabetic testing or cancer screening. Our care managers and IT staff deal with meaningful use attestation. The nurse care manager works with patients who are having difficulty achieving their treatment goals, spending more time with them than I can and getting results. Flu, pneumococcus, and Tdap immunization is handled primarily by the MAs. The medical assistants were trained in medication reconciliation and do this at each visit so I don’t have to go through the list but instead focus on the discrepancies or questions. Our nurse care manager takes care of the post-discharge phone call to the patient to qualify for the 99495 and 99496 transitional care codes.

        These are just a few examples off the top of my head at this late hour. Some of these are not available in all types of practices, but I would note that my large group practice did not descend from the heavens – it was formed by several physicians, including myself, who wanted to control our destinies and believed the best way to do so was to form a larger group. It was not easy and it was not cheap, but it has paid off in a big way.

        Controlling our own destiny is a recurring theme in many of my posts. We don’t have much control over the Congress, the large insurers, regulators, the Board, and the trial bar. That doesn’t mean we should not continue to make every effort to get them to change their ways. But we do have control over what we do. Not that it’s easy to change how we do things in order to diminish the threats to patient care, or that making changes will result in a perfect practice environment, which it doesn’t, but there are examples out there that should offer hope to those who are not ready to give up.

        • guest

          I think one factor that informs the “you’re either with us or against us” mentality characterizing so much of the debate within our profession today is our medical culture, which has historically socialized us to stoically accept whatever work comes our way.

          This concept of uncomplaining service to others worked well a generation or two ago. However, today it is being cynically exploited by third-party payers who are profiting at our and our patients’ expense. Those who speak up are frequently labeled as “negative” or “disruptive,” a label which sticks easily because our profession has chosen to identify stoicism as a highly valued professional virtue.

          I think that commentators who insist that “the sky is falling” are in many cases expressing themselves more stridently because of past attempts to shame them into silence, even though they are pointing out legitimate and serious problems with our healthcare system.

          In any case, thanks for the specific examples, which do indeed seem hopeful. Your practice is clearly well organized, and surely others could benefit from hearing (again, specifically) how you and your colleagues went about setting it up. Many of our medical leaders these days seem to spend most of their time lecturing the lowly common practitioner, generally from the heights of academia or from comfortable governmental appointments, (or even worse, lucrative administrative positions in the private sector), so it’s refreshing to hear from someone who is in a position to be an actual role model.

  • Yul Ejnes, MD, MACP

    Anger, no. Annoyance, yes. You implied certain things regarding my background, beliefs, and attitudes and I responded to them. And then you went on to imply additional things, again without knowing me.

    I do not consider myself extraordinary, because there are many others, some in much more challenging situations, who have made sacrifices to get involved in making things better for their practices or profession (or their communities, churches, schools, etc.). And yes, sometimes it is impossible to be able to make those sacrifices because of life circumstances, but sometimes it is a choice not to.

    The point of the essay is not “I’m OK, so shut up,” or something to that effect. In fact, it is a counterpoint to the binary thinking that characterizes many of the responses to the recent commentaries. The take-home message is that some have found ways to improve their practice experiences. (I don’t think that they rushed to those solutions, either.) And some of the physicians who are struggling might find something of benefit from knowing about those solutions. Writing about these solutions is not an acknowledgement that physicians are the reason for the problems in the first place or that the external issues are not important and shouldn’t be addressed.

    Again, I do appreciate your taking the time to weigh in.

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